Healthcare Provider Details

I. General information

NPI: 1639174220
Provider Name (Legal Business Name): SIDNEY NATHAN INDGIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 03/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6750 CAROLINA BLVD
CLYDE NC
28721-7052
US

IV. Provider business mailing address

6750 CAROLINA BLVD
CLYDE NC
28721-7052
US

V. Phone/Fax

Practice location:
  • Phone: 828-627-9616
  • Fax: 828-627-9215
Mailing address:
  • Phone: 828-627-9616
  • Fax: 828-627-9215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2007-00385
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME 11708
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: